Photo: Cedar Grange Care Home, 5-7 Pilkington Road, Southport, PR8 6PD


Overall summary

We carried out an unannounced comprehensive inspection of this service on 9 and 10 June 2015 and identified two breaches of regulation in the ‘safe’ and ‘effective’ domains. The breaches of regulation were related to concerns we identified about the management of medicines and application of the principles of the Mental Capacity Act (2005). We asked the provider (owner) to take action to address these concerns.

In addition, we identified a minor concern within the ‘Responsive’ domain and made a recommendation for improving practice.

Following this comprehensive inspection the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on 27 November 2015 to check that the provider had met the legal requirements identified in ‘safe’ and ‘effective’. We looked at whether the concern identified in the ‘responsive’ domain had been addressed. The ‘caring’ domain was not assessed at this inspection as it was rated ‘Good’ at the inspection in June 2015. We did not plan look specifically at the ‘well-led’ domain. It was rated as ‘requires improvement ‘in June 2015. To improve the rating to ‘good’ would require a longer term track record of consistent good practice. However, some issues were identified and these have been reported under ‘well-led’. You can read the report from our comprehensive inspection, by selecting the ‘all reports’ link for ‘Cedar Grange’ on our website at

Located in a residential area of Southport and near to local facilities, Cedar Grange Ltd is a residential care home providing accommodation and personal care for up to 26 people living with dementia. Accommodation is provided over two floors with a passenger lift available for access to the upper floor. All shared areas are on the ground floor, including three lounge areas, a dining room and a large conservatory at the back of the home leading into a courtyard and garden.

Nineteen people were living at the home at the time of our inspection.

A registered manager was not in post at the time of our inspection. The manager had submitted an application to register with the Care Quality Commission (CQC). This was being processed at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found that improvements had been made in the areas we had concerns about and the previous breaches had been met.

Staff sought people’s consent before providing routine support or care. The staff team had received training in the Mental Capacity Act (2005). Mental capacity assessments were being conducted in a generic way and were not based on a decision the person needed support with making. This meant the home was not working with the principles of the Act. We made a recommendation regarding this.

Applications to deprive people of their liberty under the Mental Capacity Act (2005) had been submitted to the Local Authority.

The way medicines were being managed had been reviewed and we found they were being managed in a safe way. They were administered from a trolley that was stored in a secure and dedicated medication room when not in use.

Risk assessments and care plans were in place for the people living at the home. These were individualised to the person and the care plans provided clear and concise information about how each person should be supported. Risk assessments and care plans were reviewed on a monthly basis or more frequently if needed. They were revised to reflect people’s changing needs.

Staff had received adult safeguarding training. We could see from the incident reporting records that appropriate safeguarding alerts were made to the Local Authority.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. We observed that there was sufficient numbers of staff on duty during the inspection. There was an unhurried and relaxed atmosphere in the home.

Staff received regular supervision and appraisal. Training records showed staff were up-to-date with the training they were required by the organisation to undertake for the job.

The building was clean, well-lit and clutter free. Measures were in place to monitor the safety of the environment and equipment. Individual plans were in place for the safe evacuation of people should an emergency occur.

People’s individual needs and preferences were respected by staff. They were supported to maintain optimum health and could access a range of external health care professionals when they needed to.

The menu was varied and we observed people enjoying their breakfast. People got plenty to eat and drink throughout the day.

Staff had a good understanding of people’s needs and their preferred routines. We observed positive and warm engagement between people living at the home and staff throughout the inspection.

A procedure was established for managing complaints. No formal complaints had been received within the last 12 months.

We noted during the inspection that CQC had not been notified of two recent safeguarding alerts made to the local authority. The manager sent these to CQC shortly after the inspection.

The ratings from the June 2015 were not displayed in accordance with the requirement to do this within 20 days of publication of a CQC rating. The manager advised that they had been displayed. It was likely the ratings were removed when the notice board was taken down for re-decoration.

Read the full report here


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